Treace Medical Concepts, Inc. (TMCI) Earnings Call Transcript & Summary

Good morning, everybody. We're going to go ahead and get started. Thanks for joining us today for Treace Medical's Investor Day Event. I'm John Treace, CEO and Chairman of the company. And it's really great to be here with all of you at the NASDAQ market site in beautiful New York City. Our disclosure is here for today's event. Here's our agenda. We've got an outstanding lineup of highly experienced foot and ankle surgeons here today. These are surgeons that all share a common passion of making bunion surgery better for their patients and also helping enable other surgeons across the country do the same. I think you're really going to enjoy these talks. You're going to get a ton of information about these new innovations, how they're advancing the standard of care and how they're going to help advance Treace's leadership in the bunion market. From the company here today, we have Sean Scanlan, our Chief Innovation Officer. We have our CFO, Mark Hair; and we have our Chief Commercial Officer, Gaetano Guglielmino, present as well. I thought I'd start off with a little background on Treace Medical, why we exist, what's made us successful to date and why we're so excited about the future we have ahead of us. This is a company that from the start in 2014 has been driven by a focused mission, a passion for improving outcomes for bunion patients. And in doing so, we went from a napkin sketch to over $200 million in revenue with essentially one patented bunion procedure that largely changed the way that bunions were evaluated and treated. And now in 2025, with an established commercial team in place and a large customer base, we're entering the next growth wave of the company, launching our best-in-class comprehensive bunion solutions portfolio. Bunions are a really big problem, and they can become painful lifestyle-limiting deformities for a significant portion of the affected population. And we believe the shortcomings of prior surgical procedures in the past, resulting in high recurrence rates and high patient dissatisfaction rates has been a rate limiter to surgery. This said, we believe there's a significant opportunity to expand beyond the 1 million symptomatic surgical candidates as we develop even more effective solutions for surgeons, solutions that can bring faster recovery, improved cosmesis, more enduring corrections for patients and then communicating the benefits to the clinical community. And we believe there's a real opportunity for us to double the business in the years ahead. We're currently around 3% penetrated in the symptomatic surgical candidate base. And with the technologies that we have today and those in our future pipeline, we believe we just need to get to 7% to 8% to achieve that milestone. Our company was founded on this realization that the vast majority of bunions had this overlooked, underappreciated third plane involved in the deformity and the negative impact that the failure to correct for that frontal plane, that third plane can have in driving high recurrence rates. With recurrence rates cited in the peer literature as high as 60% and 70% plus with traditional two-plane surgeries of the past, you can see why a breakthrough like Lapiplasty being the first ever instrumented system to allow a comprehensive three-plane bunion correction to be performed in a reproducible, repeatable manner fills such a significant gap. And that's what led to the adoption of this technology by nearly 1/3 of all bunion surgeons by 2025. And since our first Lapiplasty cases in 2015, this company has been hyper-focused on iterating and evolving our designs, constantly making them more reproducible, faster, less steps for surgeons and more recently, minimally invasive. And it's this iPhone product development model that we've employed and then supporting our surgeons with great training and differentiating clinical evidence that's made Lapiplasty the gold standard for 3D Lapidus today. And now we're applying this successful model to address different categories of bunions with highly specialized solutions that can accelerate our penetration into the market. If you look at our over 3,100 surgeon customers today, with Adductoplasty and Lapiplasty alone, we believe we penetrated about 30% of their total bunion volume. And here in Q3, we're launching three new systems, our Nanoplasty and Percuplasty 3D MIS osteotomy systems and our SpeedMTP Great Toe Fusion system. These three new offerings address significant volume segments, giving us greater access to the untapped 70% of our surgeons' cases while also allowing us to appeal to a much broader surgeon audience. And we're leveraging platform technologies to bring even more breakthroughs to market, like our market-leading SpeedPlate fixation technology and our first-to-market IntellGuide PSI technology for bunion and midfoot deformity correction. And today, we're announcing the initial introduction of our new Percuplasty MIS power system. This is a power system that powers the single-use cutting burs that are used in the Percuplasty procedure, but can also be applied to a variety of other minimally invasive foot and ankle procedures. This specialized new addition to our line cements our commitment to becoming the one-stop shop for all of our customers' surgical bunion needs. You're going to hear more about all these exciting technologies and innovations and even more coming up next from our surgeon experts and Sean Scanlan. We've got an incredible panel of surgeon experts here today to help out. Dr. Decarbo, Easley, Johnson, and Kaplan. Thanks again so much for being here to help educate this audience on these exciting technologies, the impact they're having on your patients and on your practices. And with that, I'm going to turn the floor over to Dr. Will DeCarbo. Will?

So the green, is that what you advance with?

Go green.

All right. Fair enough. Thank you, John. Well, I appreciate being here. My name is Will Decarbo. I'm from Pittsburgh. My brethren will be here in about 4 days. That may or may not make you excited with the jets and the stealers. So the return of Aaron Rodgers, but we'll get through it together. In any event, my charge here is to talk about Lapiplasty and Adductoplasty, two of our flagship and main procedures and founding procedures with this. And again, just like John said, we're super excited about this technology, not just for today, but tomorrow, we continue to iterate this. As it was stated previously, when we look at bunions, there's over 130 different ways to treat a bunion. And the way we looked at it from a company standpoint at Treace, there's not one good way. Early on, we understood this, and we understood that triplane issue that we'll speak about again, I'll show you the slide that John presented as well. But in 2018, we proposed a classification system that kind of revolutionized the thought process behind what we're seeing when patients present with a "bunion" because there were four distinct categories of patients that presented with bunion. There's mild-to-moderate, mild-to-severe metatarsal adductus and arthritis. And the arthritis is really branched into two components or two buckets. There's arthritis with the bunion and then there's a primary pathology of arthritis of the first MTP. The SpeedMTP, which Dr. Easley will talk about, covers both of those, and we'll go over that with you. One of the things that we wanted to do was to create a system. It was a philosophy change in an instrumented system in order to address each of these four subcategories, if you will, of "bunion" or midfoot, forefoot deformity. And then with that followed what we feel is a best-in-class fixation options, and we'll discuss that. For the mild-to-moderate, we have Nanoplasty and Percuplasty. You'll go in-depth on that with Dr. Kaplan and Dr. Johnson. For the mild-to-severe, we have Lapiplasty. That was our flagship procedure and really the springboard into these other technologies and these other midfoot, forefoot deformities. Metatarsal adductus, we'll discuss and then the SpeedMTP for the first MTP fusion, which Dr. Easley will go over. And the bottom, as this does the intraoperative C-arm as well as the cartoon drawing just shows you the power of this system. So what we want is reproducible, consistent triplane results with fixation that is best-in-class. And that's where we think we've landed, and that's what we're excited to present here today. The Lapiplasty, as said, our flagship procedure, one of the aha moments, and John kind of touched on this, was the frontal plane. The frontal plane has been described since the '50s. But until Treace Medical concepts, nobody has really come up with a dedicated way to assess it and a dedicated way to fix it, and that's what we've done. The transverse plane is kind of intuitive. So the cartoon drawing here where you see the bump, we can understand that there's a transverse plane deformity, and that's the prominence. And what's really interesting about it is there's a common misconception and that's a growth or a bump and you can just shave off a bunion. The reality is the midfoot joint is unstable, and that allows that bone or that metatarsal to drift out of alignment, creating that prominence, and then the big toe kind of deviates to the lesser toes, and that's the deformity you see. So the transverse plane, you can see that any lay person can see it. The sagital plane, the metatarsal actually elevates. And you get a glimpse of this on radiographic analysis when we look at this, but the frontal plane was really the key. The literature bears this out. When you look at work by Kim or Okuda, if the frontal plane deformity is not addressed, there is anywhere from 10 to 12x the likelihood of recurrence or patient dissatisfaction. So this really is almost the missing link, so to speak, of bunions. And what Treace did was develop systems that take into account this triplane correction that's instrumented each time for this. We tried to take an approach that simplifies the process. So all of our options come down to 4 or 5 steps. And you can see through guided instrumented systems that created not only consistent results, but what it did was it took the variability of the surgeon out of it, good day, bad day, and where you train. We were talking outside here with some of the investors and really bunion surgery depended on where you train, what part of the country you train, what was prominent in that area, and then that's what surgeons did, not necessarily the best option for the patient. And what we wanted to find was the best option for the patient that's consistent and this triplane correction is what we came up with. In 2015, we started with an open technology. So we were around a 7-centimeter incision in order to use all the instrumentation in order to get this done. As we develop an understanding for not just the pathology, but also the instrumentation, we were able to take that incision smaller and smaller. And really one of the main thrusts of this, how can we get the same triplane anatomic correction through a smaller incision. And it's the iteration of the instrumentation in order to do that. So as we started with 7 centimeters for Lapiplasty, we now can go to a Micro-Lapiplasty through a 2-centimeter incision. We believe this is very important for a lot of reasons. The morbidity of surgery is something across the board, whether it be general surgery, vascular surgery, any part of orthopedics. The amount of damage caused to the body, the deconditioning is really powerful and it really matters. With the advent of these smaller incisions and minimally invasive surgery, we're doing less scarring, less deconditioning of the patient. So this is really a great iteration to start us moving forward. And then we'll talk about the fixation last. It will be a dedicated slide because as we went into instrumentation that allowed us to do these procedures through smaller incisions, we needed complementary fixation in order to fit through that procedure. The Micro-Lapiplasty for Lapiplasty was the first advancement in this MIS technology. And two main things came out of this. One, what we call an external positioner. And so instead of that cup being put on the bone, we were able to do it on the outside of the skin. That alone lengthened the incision by several centimeters off the bat and then the cut guide. The cut guide was narrowed on the transverse plane and thin. And what this allowed with a percutaneous approach, just the width of the saw to get in to make the appropriate cuts. Once we did that, complementary products came out because now we had to retrieve the bone out of that joint in order to create the fusion. And so we have LapiTome, RazorTome, and then SpeedRelease. And these are instrumentations that complement the MIS surgery because when you're working through a 2-centimeter incision, that visibility and that ability to get the bone out that you just cut is critical. So we developed this. And then lastly, which will be coming up, we'll show a dedicated slide is SpeedPlate. The SpeedPlate technology is really unique. I'll save it for the slide on this, but why this was developed is because as we went through these smaller incisions, we need an implant to fit through these smaller with the same load to failure and cycle to failure as the traditional plating. At this point, we've had thousands of patients treated. We had published papers. We had the data. So we needed to recreate those same results through a smaller incision and all this instrumentation helped to do that. You'll see several instruments here like an incision guide and some release tools that we'll talk about. But what we noticed early on is to do these procedures through the smallest incision possible, you had to really know where you were anatomically on the foot because that incision mattered. If you want to go through a 2-centimeter incision and you're 0.5 centimeter off over top of that joint, well, by definition, you're already at 2.5, and that wasn't the goal. So for this and Adductoplasty, we have incision guides for this. So dedicated instrumentation in order to do the same triplane anatomic correction at the tarsometatarsal joint, you can see the size of the guide. So that became the rate-limiting step is how do we do the same procedure through this and it developed into this system. That leads us to SpeedPlate. The SpeedPlate technology is really fantastic. Mark will talk about the SpeedMTP. This is where this kind of comes from for the first MTP fusion. But the idea was not only did we need an incision smaller, we needed fixation to fit in that incision. And then for efficiency, how do we get this plate and 4 screws in is one monolithic structure. And then what was developed was 4x that act as those screws that go in all at once, and then we lessened that to a 2x SpeedPlate and then a MicroQuad. All that is, is to create the stability we have with BIPLANAR plating with traditional plates and screws, but allow that circumferential stability. This is very unique because it functions as a plate. It goes in with the ease and efficiency and the compression of a staple, but it really is designed off of our traditional 4-hole plate -- or I'm sorry, yes, 4-hole plate and screws. It does not contain nickel, and it's anatomically contour. The anatomic contour allows us to be placed on the bone segments where we want it without impeding into any of the soft tissue structures like the tendons, without impeding into the surrounding joints. So this has really been a iteration that has transcended Lapiplasty, Adductoplasty, and first MTP fusion. These plates are even used in hindfoot, midfoot fusions, fractures, these sorts of things. So this is really good. When we look at our triplane correction through a small incision, you can see the pre-op, the post-op, and then the clinical image. And again, the goal was triplane correction like we had through a smaller incision. You see the incision there, the lack of length on the incision, the lack of swelling within that area. If you compare and contrast this to our traditional open, you see on the right side, there was a traditional open incision with maybe 7 centimeters. And then we have our 2-centimeter Lapiplasty. And besides this skin, obviously, you have the less trauma to the tissue. The x-rays, what I want you to focus on for one reason. We wanted the same triplane consistent approach through a small incision, and we were able to capture that with Micro-Lapiplasty. So that's really the key to this. So that is Lapiplasty in the iteration through Micro through the 2 centimeter. As we move on, metatarsal adductus, metatarsal adductus is a very important condition with bunions. We'll get into the statistics in the subsequent slide. But one of the things we realized as we were able to dial down what we call intermetatarsal angle or corrected deformity of the big toe, we were getting down to 0 to 4 degrees. And there was a subset of patients that even if we got down to 0, they still had a deviation of their toe. And it looked like clinically, they still had a bunion. And this is a subset of patients that's called metatarsal adductus, and I'll show you a slide on this. In a traditional bunion, just the bone behind the big toe called the first metatarsal is deviated out of alignment. And for that, we have three offerings of triplane correction, Nanoplasty, Percuplasty, and Lapiplasty. With metatarsal adductus, the two midfoot metatarsals, the second and third also deviate with the first. And that creates an entire midfoot deformity and you can see you can make an argument with the space between the first and the second metatarsal, the long bone behind the toes, is not really increased. But yet they have a clear deformity and a clear bunion. So we needed a system in order to do a triplane correction with consistency in order to fix that. Before Adductoplasty with Treace Medical, this deformity was just overlooked for the most part. There was no consistent way in order to correct this. So you can see that the deformity in the foot, both radiographic and clinically, still persists. And what that does, that leads to very dissatisfied patients to say the least. The number one question that we got is, well who needs Adductoplasty? When we do it? Who has metatarsal adductus that we needed? And we came up with a system called a Plumbline. We published this in 2023, the second half, that's not on here is very famous. Thank you Sean. But the idea of this is a we took a line from the medial midfoot bone called the cuneiform and extended that laterally where the first metatarsal would line up to the cuneiform in a corrected position, and if that line did not touch or cut into the second metatarsal that's what we call Plumbline negative. That means we have enough room to correct that first metatarsal with Nanoplasty, Percuplasty, or Lapiplasty. In contrast to that and this is the animation going over. In contrast to that, you see the foot to the right with metatarsal adductus, we draw the same line and extend it and it crosses into the second metatarsal. And this is very intuitive. Patients understand this immediately. Most importantly, other surgeons understand this immediately. And if you look, if I correct the first metatarsal into its anatomic alignment, the first and second metatarsal compete for the same space. So we physically do not have the room in order to do it. So we have to consistently move the second and third metatarsal out of the way, and then we can go forward with the first metatarsal for its anatomic alignment, hence, the birth of Adductoplasty. And what that came out of 4 steps, just like the Lapiplasty where we prepare the joint, cut the joint, compress the joint, and fixate the joint. And again, this takes a very complex midfoot deformity that had no real consistent answer, and it made it streamlined and consistent with the results. Just like everything else, this started out as a full open procedure, about 7 centimeters. And then over time, as we learned from doing the procedure and understanding instrumentation, we can get this down to a Mini-Adductoplasty through 4 centimeters. And a lot of times, that could even be 3.5. That is my take, not Treace Medical. So what we realize is we don't have to cut both joints at the same time, and then you can see the instrumentations. Just like every iteration of the instrument or the system, instruments followed to complement the procedure. We have to have a robust release between what's called the base of the third and fourth metatarsal, hence, the TriTome, which is a single-use instrument, and then there's multiple guides. And what's unique about the Adductoplasty is we also have single and double, no deformity of the midfoot, just primary arthritis. So we have a guided system to fuse in isolation, the second and/or second or third just for midfoot arthritis, which is also very common. You saw the SpeedPlates at the end. The incision guide is a consistent theme. We have to be in the right spot. So we know that our incision stays within the boundaries of the length that we want. You see the guide was reconfigured. So it's the same transverse plane and cut angle. It's just reconfigured in order to cut one side at a time, and then you can see the results. And the idea is the less trauma to the surgeon, you have a 3.5, 4-centimeter incision, a 2-centimeter incision that handled a very complex midfoot deformity. And it handled it with a guided system with minimally invasive approach to it. So really fantastic, and you can see how the skin heals and how the foot looks afterwards. So those are our two flagships, so to speak, procedures of Lapiplasty and the iteration of such and Adductoplasty and its iteration, and then my fellow colleagues will go over the rest of the systems. But I appreciate your time and attention to this. Thank you. Now am I introducing Mark? Okay. Dr. Mark Easley from Duke. He's not limping. He had knee surgery.

All right. Thanks, yes. I'm Mark Easley, I'm at Duke, and I'm with my colleague, Jonathan Kaplan, who's here as well. And I'll try to talk to you off this thank you slide. Is there something, I just advanced and it's good. Yes. All right. So bunions are very common. I think you've got that. And what I'm going to talk to you about is arthritis or when the white shiny surface starts wearing away on the big toe joint. So I'm looking at the category. Will already showed you this, but I'm looking at the category that's all the way down at the end there. So that one there, where we're talking about what do you do about this arthritis? And you think, well, arthritis, you have knee replacements and joint replacements. Well, for the big toe joint, we're not there yet. So what we typically do is a fusion or mending the joint together and you think, wow, you're going to fuse that joint together and how is somebody going to walk? How -- if you don't move your big toe joint. That's what we're going to talk about. It's a very common problem. So there are tens of thousands of bunion surgeries done in the U.S. every year. And this problem is a close second. So arthritis of the big toe joint, there's thousands and thousands of these operations done, these fusions of the big toe joint. So what is Treace Medical going to do? I wasn't one of the founding surgeons to work with Treace. I actually approached them and said, "I'm starting to do your operation. I love what you do. Could I somehow be involved?" And they invited me to be part of the team because it's the right way to do it. And what I want to emphasize today is that all of these instruments you'll see and these cool products, and they are important, but what Treace does really well and the surgeon advisory team does, it's really the philosophy of how to do the surgeries. And if you look at other products on the market, they typically roll these out with the screws and the plates and say, okay, have at it. What Treace does much better, in my opinion, that's why I joined the group or asked to join the group selfishly, was it's a philosophy, right? It's like the surge where they teach you how to do the techniques. Nobody teaches surgeons how to do surgery better than Treace Medical. And I am a consultant with other companies, too. This is hands down the best approach to teaching surgeons how to do the techniques. And oh, by the way, we have some great instruments too, to make that better. So that's the distinction there. But we're going to talk about arthritis, the big toe joint. So you can have a bunion just like Will eloquently just showed you and talked to you about, but you can have it with arthritis. So Will or the others can make that toe as straight as they want and then cosmetically, it will look nice, but it's going to be incredibly painful because it's grinding bone on bone. We don't want that, right? So that's when we talk about doing a fusion. Now there's a whole another category, which I mentioned, and that is the toe is straight, but it has arthritis. Again, incredibly common problem, tens of thousands of these done every year in the United States. And unfortunately, not done exactly perfectly, but that's called hallux rigidus, just a stiff big toe, right? So this year, there are studies done that show that if you are -- have a stiff big toe joint, you're very debilitated, but there are also studies that show if you fuse that joint and make it pain less, even though it's stiff, you're still incredibly functional. You can play sports on a big toe joint. You can run on a big toe joint that's fused. So it's not as though you're going to debilitate these people as long as the toe is put in an anatomic position. So Will just talked to you all about the triplanar correction. These same principles apply to the big toe joint fusion. I don't think surgeons fully understand that, but Treace and the team really teaches that well and then provides you with instrumentation to do that surgery well. So this is a patient walking down -- you've been to the doctor's office, just walking up and down the doctor's office here. And you can see that it looks pretty natural, right? And you could even have this patient do some exercises or run, if you want, but it's really hard for me to tell that, that big toe joint has been fused. So as long as it's put in the right position, the surgeons taught how to do this properly, and you have instrumentation to make it fused reliably and have them be able to walk on it right away because it's stable fixation, then you'll be very natural and be very physiologic. The competitors are out there. Look at this. This is all over. MTP joint fusion is a very common orthopedic procedure. We do this on a very common basis along with bunion surgery. The problem is sometimes the -- or often the implants are very bulky. They are not necessarily taught the technic. Everybody knows how to say, yes, a common procedure, but there's some subtleties to it that need to be taught properly so it's done correctly. And so mistakes can be made. The toes put in the wrong position, that's symptomatic and a problem. The plate is too bulky, it's symptomatic. There are ways around that. So what really what Treace does is take a common problem. Well, one, you learned from Will, here's a problem that hasn't been defined. 130 bunion surgeries. We got to make this reproducible and more consistent. In this year, yes, a very common operation, but what Treace does well is innovate and make it better and make it reproducible. I work with residents and fellows, people that I train. Every one of them says, "My God, this SpeedMTP, it is so easy and intuitive and it's reproducible," and that impresses upon me. I just showed it to them one time and said, this is a system I'd like to use. In addition, there are other instruments like Will showed you that make the operation easier that the competitors, yes, maybe they have some of these, but usually have to scramble in the operating room to try to find some of these things. These all come in the kit. So ways to make it easy to expose that joint it's already stiff. So it's easy to work in that joint -- ways to smooth the surfaces because it comes with bone spurs, right? It's arthritis. It's going to make bone spurs. And then you have a system with that SpeedPlate concept, SpeedMTP and a way to target screws so they don't interfere with one another, the way the times work so that the plate continues to compress to make it more stable and then a way to add screw fixation to pull the plate down to the bone and make this incredibly stable construct that allows the patient to walk on it right away. Yes, they have to protect it some, but it's not as though they have to get a knee scooter or they have to be laid up in bed. They can get right back to their activities and for 6 weeks have to protect and then they can get going on this. Again, here are some of the instruments with it, but it's the same speed plate technology applied to the big toe joint. That's unique in the system in the competitive market. And it's the principles of the technique and then having instrumentation to put this implant in properly and then have it work for you. And it's low profile. So seek here, there's arthritis. So sorry about the graphic pictures. But if you look here, it's bone spurs, you get the idea. We can smooth those down. This FeatherRasp idea, it can be applied anywhere, but really slick tool to make this easier, so you can contour exactly the bone that has spurs on it, so the plate and the instrument -- the implants can sit perfectly anatomically on the bone. And then a targeting device, if you can imagine, if you're putting 4x in a bone, a little bone and just a big toe joint, and then you have two screws go in and you want to put one extra screw in for fixation, something is going to collide, right? And you just don't want that to happen. You don't want to slow down the process. You want to be longer in the operating room than you need to. It's a targeting device, so that never happens, make it a lot easier for you. So you can see here, sorry, pretty graphic. I know, but it could be worse. It could be worse. But this is what we do, okay? So we're sharing with you with what we do. But it's a way to make it easier to get into the joint. You see this little tool here. It's really -- I mean it's a medical art, right? So it's actually -- this is artist work. And that way, these instruments can say this is actually one of my surgeries. So you can see here where everything sits nicely because we've contoured it perfectly. We've positioned -- we taught the technique how to get the toe in the right position. And then it just -- it's step by step, it's real quick to drop these in. And then here's the implant, sits in very nicely. And you can actually -- it's so stable. You can actually we're carpenters, you can hammer this in place and then drop these extra screws and they give it really a nice fixation. So good, all right. Just -- you just have to be patient, we'll get through it. And you can see here, this is in the operating room, then you can see how stable that is. In other words, it's stable, you can go right away and walk on this, not dance on it, but you're going to go walk on it right away because it's stable. And here it is in the process of -- it's nice, it's low profile, low contour. And you can see around that implant to make sure the bone is healing the way you want it to without it being obscured by the hardware. Here's a bunion surgery. So bunion surgery, again, some other techniques. Not that that's wrong. It's just that sometimes those don't work, and this is how we salvage it with the same operation where we do a fusion. You can see the patient is incredibly happy. How do you know that patient is happy from preoperative to postoperative. How do you know? Quick. Good toe nail. That's exactly right. So it's good anyway. But you get the concept. But what I want to emphasize with you is that, yes, there's a lot of innovation and new things to take something that's complex, 130 different bunion operations to try to get it down to something that's reproducible, predictable, and works for patients and works for surgeons, but then also something that's very established, a big toe joint fusion, again, a very common operation, but we can make it better. And what impresses me is that Treace puts the effort in to make that better. Holly, I think, is next.

All right. Good morning, everyone. I'm Holly Johnson from the Hospital for Special Surgery right across the island. And I'm going to talk to you today about some of the more percutaneous options for bunion correction and try to give a little background, but also give the thought process behind why Treace would enter this market. So you've seen this slide a couple of times, and I'm going to address Class I, and this is where we have a fairly straightforward bunion deformity without adductus and without arthritis. And we have two new options for that, Nanoplasty and Percuplasty. So when we think about how surgery in general has gone from open procedures to more minimally invasive procedures and virtually every side of surgery, even open heart surgery, general surgery and in orthopedics. And I think to make it the most relatable, everybody in this room has either had an ACL reconstruction, a knee scope, a shoulder label repair or they know someone who has. And if you think about those people in your life who've had those operations, it's all done through small incisions. And really, the entire market is going towards small incisions for obvious reasons, decreased pain, decreased swelling, et cetera, faster recovery. And so when we think about the advancements in arthroscopic surgery, it started from advancements in the technology and training that allowed every surgeon to do it. And at this point, I don't -- I can't imagine a surgeon doing an open rotator cuff. It's just completely gone. It's off the table. That procedure is not done anymore. And I think that as we move forward in bunion surgery, we're going to go in that direction. So again, some graphic photos, but I think that it really makes the point that when we look at the foot on the left-hand side, traditional open procedure and the foot on the right, what person in their right mind would ever want the surgery on the left, honestly, right? There's not a single person ever who would rather have that surgery than the other surgery. So when we think about that and what's available out there, Treace saw an amazing opportunity to expand patient interest in surgery. So historically, and for those of you, there are probably some people in the audience who have bunions or have a spouse that has a bunion, traditionally, even the primary care doctors say, you should never have bunion surgery. It hurts so much. It's going to take years to recover. It's never going to be good, literally wait until you can't put a shoe on anymore. That is the worst advice because we know that from when a bunion starts, it continues to get worse over time. And as it gets worse, the toes get involved, the foot gets much more problematic and the ability to fix the foot in a nice way is basically eliminated. So there's a subset of patients out there who want to have the bunion fix, but they're afraid. And so now people are seeing, look, we've got these minimally invasive approaches that have less pain, faster recovery, I want that. And so they're coming into their surgeon's office, and they're demanding those techniques, okay? And I'll say just anecdotally, I do no marketing. I'm not on social media. My hospital doesn't really do any marketing for me. I literally have to push. I have so many bunion patients. It's like they come because I operated on Susie and then Susie's sister comes and sees me and I do both of her feet and then she goes and gets a pedicure and then the woman who does the pedicure comes to see me and it's just this circle of people coming in because they see a fast painless recovery. So when we think about where we are in the country of the current state of bunion correction, it's a trade-off between patient benefits and technically challenging surgical procedures. So this is me doing the procedure on the left-hand side of this video. And basically, many of you may have seen it out there, but you have this power device with this -- it's essentially a drill on it, and that's how you cut the bone. And the drill diameter is 2 millimeters. So I can cut the bone through a 2-millimeter incision as opposed to a more traditional way where you have to have exposure for the saw. It's a complicated procedure where I cut the bone, I shift the head, I put in wires percutaneously, meaning not through an incision and then I place two screws, and that's what the foot looks like at the end. Those are the incisions. No incisions on top of the foot. And the problem is that it's really hard, and it's taken me a long time to become proficient enough to be able to do this in a reasonable time frame and to be good enough to really want to offer it to all my patients. So when we look at some of the x-rays that are out there, and I know that there's -- I'm showing three different x-rays here. These are all percutaneous or minimally invasive bunion surgeries done really poorly. And these are people who even post this on LinkedIn and think these are done poorly and the patients aren't going to do as well. And so when these patients come in and they say, I want minimally invasive surgery, but I don't understand why everybody is not doing it. And the reason is it is because the surgery is really hard. And it's a difficult surgery to learn. It's a difficult surgery to teach. And if you think about how many you have to do to become proficient, it's anywhere from 40 to 50 when you're using a freehand technique. Most bunion surgeons may not be doing 50 bunion procedures in a year. So why would they want to adopt a surgery or a type of technique that's going to take that long to do it when they can do it the old-fashioned way and maybe they don't get as many good results, but hey, they can do it. Well, the problem is that now we have this entire patient population that was never going to have bunion surgery before that wants to have surgery, and we need to teach the surgeons how to do it. So this is where Treace comes in. And basically, they've come up with two instrumented systems designed to dramatically reduce the learning curve of a 3-dimensional minimally invasive surgery. And so there are two options that address really, I think, two different surgeon populations. There's Percuplasty, which is the screw technique that you saw me doing percutaneously, but now we have an option for a gig. And then Nanoplasty, which is an intramedullary device, plate system that surgeons can still do with a saw if they don't feel comfortable with the burr, but they can do it through a very small incision. And so with the Percuplasty, it's a few -- very small poke holes in the skin. And with the Nanoplasty, it's one singular 1.5 centimeter incision. So again, thinking about, well, does minimally invasive surgery work? Well, we know it works. There have been multiple studies that show that you can get rotational correction. You can get that 3-dimensional triplanar correction using the minimally invasive system and you can have successful outcomes. And there are multiple studies that have come out over the last 5 or 6 years that show excellent short-term and long-term results with this distal osteotomy technique. And now, of course, we have these patients coming in who want the surgery, and we're going to develop a system that's going to allow the surgeon to do it better. So if we think about the Percuplasty portfolio, there are three aspects to it. So there's a 3-dimensional correction and targeting guide. And this is where I would say for Treace, it was better to be a little later to market. And so there are other jigs that are out there on the market now from our competitors, but honestly, the jigs just don't really help the surgeon. They're very bulky. They're difficult to even get on. They don't get that 3-dimensional correction. They're only correcting the bunion in two planes. And if you recall where Will DeCarbo was talking about how you need to get that rotational correction, none of the jigs on the market other than Treace correct for that 3-dimensional deformity. So you can get the correction where you want it. It makes it very simple to place the screws and essentially makes the procedure much more boiler plate, which goes along with Treace's mission. There's a plug-and-play MIS power system that you can bring into any ambulatory surgery center into a hospital that makes it simple for any surgeon to have access to the burrs and then the screw system, which is pretty unique as well. So looking at the targeting guide, you're essentially making those same incisions. You're sliding this guide in and the jig or the guide itself helps you to dial in the shift of that metatarsal head, but then also rotate it to get that rotational correction, that triplanar correction. It holds it in place. And another advantage of this jig is it's essentially hands-free. So a lot of times when people are doing the bunion correction, they need two hands. They need somebody to hold the correction and another person to fire the screws. This jig allows a surgeon to do it single-handedly. You place your wires and then very easily place the screws over the wires. When we think about the screws themselves, the heads are beveled, which means they're angled and they sit flush against the bone. So that you're not feeling those screws through the skin and there's a much lower rate of hardware removal. They have a self-drilling tip. And what this does is it makes it so you don't have to drill the bone over the wire. And it basically just simplifies the entire workflow and you save time in the operating room and effort. And here's the screw going in. So thinking about case examples. This is an example of -- I don't know if you can get the sense of shifting the head, putting in the screws and then it's 6 months. And yes, this patient has had a pedicure because they're quite happy. And that's actually a sign of a successful surgery, I agree. So just addressing the market that's out there, we have two populations of people that we're capturing with this new minimally invasive technique. We're capturing all those -- I mean, largely women who've been afraid to have bunion surgery in the past because of the pain and everything else. And I will say, from a pain standpoint, one of you asked me earlier about pain medication. My patients take no narcotics after surgery. And if you think about historically where bunion surgery has been described as very painful, this is not a painful operation anymore. And then we're addressing the surgeons who need to learn the technique, and we've got a great solution. Thank you.

Hi, everyone. I'm Jonathan Kaplan. I'm also from Duke University like Mark Easley. And I'm actually going to leave this slide up for a second before I go on because I get to talk about the Nanoplasty, which I like that is in the middle because I'm kind of giving you the best of both worlds. And I think that's something that's a nice feature for most of our surgeons that are doing these procedures. And so like I said, this is who I am and where I'm from. And really, you've seen this over and over again, and there's a reason we're showing you this slide repeatedly because it really does make sense. It helps surgeons develop an algorithm for their approach because historically, like Will talked about, most surgeons did what they learned, what they trained, what was in their area. And that's not really a good way to practice medicine. We want a way to sort out what patients need different procedures so that we can have more predictable results. And I'm like Holly going to talk on the mild-to-moderate deformity of these distal osteomies and specifically, I'm talking on the Nanoplasty, that medullary system. And so why are we talking about this in general? So again, these are instrumented systems that accelerate the growth, accelerate reproducibility for our surgeons, and we're decreasing the recovery for patients. And one of the challenges with the osteotomies, I think Holly did a tremendous job explaining it so well that I don't have to hammer it out. But even admittedly, I'll say these are hard procedures. Holly and I have been doing them for many years at this point, and we even struggle still, right? And so think about the average surgeon who's not doing hundreds of bunions a year. It's going to be hard for them to adapt a procedure that is technically challenging, that they struggle through the surgery, they have unpredictable outcomes because at the end of the day, we care about our patients, and we want our patients to do well. And so these are those black diamond procedures, and we're bringing them into that beginner. We're going to see them go into the green target that we want. And these are accelerating that recovery and accelerating the MIS procedures. And Holly talked about it. Why are MIS procedures important? Well, we see this. There's good data that shows patients have less pain, less risk of wound complications, less swelling, shorter recovery. That's what patients care about. And then there are surgeons and surgeons want precision, they want adaptability, they want accuracy. They want this to be more streamlined in the operation so that they can have a better outcome. And that's what these systems do. Now the Nanoplasty specifically kind of meet surgeons in the middle because you've seen Will talk about the open procedures where we're using saws, we're looking at everything. That's something that surgeons are used to throughout their training. At the same time, Holly showed an example where she's using a burr. A burr for us, Holly and I is very natural now, but it's not necessarily natural for the average surgeon who doesn't have experience. And so the Nanoplasty allows surgeons to use a saw through a very small incision, allows them to be accurate and then use the instrumentation to correct the 3-dimensional deformity where they want it to be. And hopefully, you'll see that as we go. This is a comparison of what these look like. So an average bunion surgery done open, it's usually as small as 3 centimeters, can be up to 7 centimeters in size, whereas with the Nanoplasty, consistently, it's 1.5 centimeters. But then the other thing you don't see in this, but you'll see in the next slide, and I know Mark said, you're eating, so just a forewarning. With the traditional procedure, we're actually having to lift all of the soft tissues. So it's not to be too gory. Imagine we have to lift everything off of the bone to be able to see it and do what we need to do. And logically, it makes sense. It's going to be more painful. It's going to have more swelling. It's going to have a longer recovery. That's why these horror stories exist with patients. That's why for years and years, patients have been afraid to have bunion surgery. Whereas even with the Nanoplasty, it's 1.5 centimeters, but you don't have to lift the soft tissues, you're working through this nice little pocket and you're able to do everything through that small incision. So this is what it looks like. You can see the comparison. I won't leave this up too much, so nobody gets nauseous, but that's the difference there. And this is what it looks like in recovery. Now this is what patients see, right? They're not looking at their surgery. They're not watching their surgery, so they don't see that open picture, but they do see the after effect, right? And the things that they're looking at. They're looking at the alignment of their nail like Mark talked about. And then when you take the dressings off, they're looking at the size of the incision. And you can see the difference here. The picture on the left, it's a large incision, but not just the incision, you see bruising tracking down the toes, tracking up the foot. Patients can see that. Whereas with the smaller incisions, really what sticks out on the picture on the right is actually our surgical marker. That's purple lines that we draw on the anatomy, you can barely see the incisions and you see less swelling and patients are happy about that. They can get back to life quicker. So what does the Nanoplasty do? Well, just like everything else, it's step by step, it's instrumented. It's allowing a 3-dimensional Triplane correction. And so the first step is we're going to have a precision-guided cut with a saw, which again is very natural for most surgeons. We're able to insert the jig through that small incision. And we're really able to work through that small incision, we're able to correct all three deformities. So we're able to translate, meaning we move the head over into a position that we want it to be. We're able to angulate it. So looking from the side, we're able to get it lined up well. And then really that third plane that is absolutely critical is the rotation and you're able to dial that in and it's possibly my favorite part of the procedure because it's very precise and accurate, and you're going to see an example of that in a second, and then we're able to fixate it. And the key with these minimally invasive procedures is we don't want to compromise outcome, and we don't want to compromise recovery, just to have smaller incisions and less swelling and less pain. And so that's what these do. They're really strong, stable constructs, allow patients to walk right away, allow patients to maintain good alignment because at the end of the day, the patients are looking for three things. Number one, they don't want their bunion to come back. They want predictability. Number two, they would like to have less pain with the surgery, with the recovery. And number three, they'd like to get back to life quicker, have a quicker recovery, and that's what this does. And so this is what it looks like on an x-ray. The first picture on the left is where you can see our cutting guide. So we're not just randomly making this cut. Surgeons can see on an x-ray where the cut is going to be. And again, they can use a saw that's very familiar and natural to them. And then in the middle picture, we can see we're inserting that guide. And I'll bring your attention to the middle and then the third picture because there's a pin you can see coming in at an angle on the metatarsal head. And then in the third picture, you see that it's up and down. And what that's doing is that's essentially rotating. That's giving you your 3-dimensional rotational correction. And we'll show you an example what that looks like in a second. And then this is our fixation on the right. Now what I didn't talk about earlier, but I'm going to point out here is it's also very low profile because what we don't want to do is we don't want to remove the patient's bony bunion, meaning their anatomy and give them a metal bunion, meaning give them hardware that's prominent and palpable and symptomatic where they have to go in and have another surgery to take it out. That's why Holly talked about the bubbled screws being low profile, and that was the goal with the Nanoplasty as well, and you can see that. And so again, this is probably my favorite part of the procedure, which is the rotation. And essentially, it's very precise. Notice how we're just gently dialing it in. We're just turning in a controlled fashion, and we can be very, very accurate getting our rotation. So we're not trying to get it in the ballpark. We're getting it exactly where we want. We're essentially hitting a home run. So this is what it looks like through the recovery. The picture on the left is preoperatively where you can see that they have an angulation in the bone. The picture in the middle is immediately postoperatively where you see the fixation. And a lot of people ask me on the drift and try not to trip. A lot of people ask, does it really heal in, in this area. And that's what we've seen over time over the years. You saw that with Holly's examples, and you can see it on the right, where all of that is new bony consolidation and new healing. And a lot of patients will also add something called an Akin osteotomy, which is we'll do an osteotomy in the proximal phalanx, and that's where the Percuplasty can come into play as well with this. So really, it gives you a comprehensive portfolio, a comprehensive package for these patients. And then this is another example, and I like this one because you can see the clinical photo on the right, where you're looking, they're about 3 months postoperatively, common theme, their nail polish is done. They're back in regular shoes, they're running, they're active. You can barely see the incision. You're really just looking at the skin folds. And so it's really nice. And then imagine that's looking directly medially from the inside. Imagine looking from the top, you can't see any incisions at all. A lot of our patients will come in at 3 months and say two things, well, three really. One, when can I do my other side? Two, I sent a lot of family members to you; and three, most people don't even know I had bunion surgery. And I think for us, that's important, right? That means they're happy. And so this is really kind of combining the best of both worlds. And again, it closes the loop, giving you a really comprehensive portfolio, but in a really nice algorithmic approach. So we're not guessing how to treat bunions anymore. Again, I'm going to bring Mark Easley, my partner back up to talk about the IntelliGuide.

All right. Sorry, stuck with me one more time. This is good. So I do have a question for you. How often do you go to a meeting and you're not prepared? Can I see a show of hands? Really? How many want to do that? You really want to be prepared. Okay, good. Okay. All right, that's good. Spontaneous off the cuff. But what I love about this, so this is Patient-Specific Instrumentation, okay? So PSI, and we're talking about -- we really can talk about all of these things with this, but we'll focus on really these two center ones so that Lapiplasty or the Lapidus type procedure where the first ray that bunion is corrected or if you have that adductus problem, you have to correct as well. So that's what we can address. So what's the difference here is that we can actually go to the operating room now with a plan in place. So we're not winging it. We're not seeing what might happen. We have a predictable plan going into the surgery. And this is not new in orthopedics. This is not new in surgery. This is a lot where surgery is going that we have the technology now where we can actually plan things ahead of surgery and then go in with that plan and execute that plan. So here it is, we use a CT scan, so a CAT scan. So it's a 3-dimensional way of looking at x-rays. I know that -- or the foot. And I know that before it was mentioned that one of the mistakes is looking at bunions in particular, in 2 dimensions. I'm also a total ankle replacement surgeon. And there are very few total ankle surgeons now that do total ankle replacements by winging it or just guessing where it needs to be. We're pretty good at that, but we can use Patient-Specific Instrumentation, a CT scan to put those components, those metal pieces and just like hip or knee replacement in the proper position. And so we can do that now with bunion surgery, too. And that's, again, that innovation that Treace brings to the table of looking at how can we predict this ahead of surgery. What you see all the way on the right after the CT scanning planning has been done is actually these cut guides. So you saw a lot of different cut guides and a lot of different instruments today, but same principles applied, planar is in place. And guess what, the cut guide is not being put on and we're looking at a fluoroscopy or that live real-time image in the operating room. We actually put the cut guide on that's premade for that patient. So we have that, that's a little model in the operating room. So you get the haptics, if you know what that is, right, where you get a feel for that model comes sterile in the operating room, you get a feel for how that sits on the bone. You can look at it even before the surgery starts. This can be sterilized. And you take that and put it on to the patient. So it's a patient-specific guide because it's going to make the cuts then as long as you position it properly, exactly where you need it to be to get the correction you already planned. So this is really looking innovatively into the future where to go. Really old slide of an old type of ankle surgery that was done freehand for emphasis really. The ways we can do this with instrumentation ankle replacement surgery. And that's what I was talking about before. There's a patient-specific guide. So surgery has been planned. Where do we want to make the cuts in that ankle bone so the component sits exactly where we want it to be, and we're not guessing or trying to fiddle with it in the operating room to try to get it right. Same thing for bunion surgery. So where can we use this? What can be just a straightforward bunion. It can be that metatarsus adductus bunion. It can be a bunion or a foot surgery that's previously done and potentially not done well or there were some complications. And we can correct that as well because we can make a preoperative plan and decide how to do it. So here it is, right here, we got the cut guides based on 3-dimensional analysis. And this can be personalized. I like that word. But what it really is, is going to your meeting, having planned for the meeting, knowing exactly where -- what your strategy is going in and knowing what the end result is going to be because you've planned it ahead of time and you're going to execute it based on patient-specific instruments for that, which I think is terrific. So you see that here, all these measurements mean something to us, but you can understand that we can take a computer now and do all this, so we don't have to do all the heavy lifting with calculations that can do it for us. And what we really want to end up with is a plan like this. So here's the preoperative X-ray. Again, we're looking under the skin. So here's the x-ray. You've seen a lot of this already. And what we want to end up is where the green is, right? And that's in 3 planes. So we're going to move that we correct the bunion. If for some reason, we have that metatarsal deduct, we're going to move those other metatarsal out of the way. We'll put the bunion where we need to be. We'll correct that in 3 planes, get the rotation exactly where we want it to be. And we can tweak that, but it's all done before we ever step foot in the operating room. And here are these patient-specific cut guides. So the beauty is that the trees team is available. So if surgeons want to do this, say they're a little unfamiliar with this potentially, the Treace team will sit with them with the engineers and go over the plan with them and little tweaks are made and there may be some surgeon preferences and those can be all built into these cut guides that are patient-specific, specific to that particular patient for that particular bunion deformity. But the big picture is that, that's a reproducible technique that can be done over and over and again. And I think if you look 5 years from now, 10 years from now, this is where it's going. We'll be even more innovative and Treace will continue to be at the forefront. But the idea is that we're pushing this forward where it's very predictable. And I don't have to do all these little adjustments because I already know where I need to be. I just have to put the guide in the proper position and make the cuts and then finish the operation from there. Yes, some more graphic pictures, maybe Holly would be disappointed in me because I actually made an incision. But you can see here that it's a patient-specific guide, but I can look at a preoperative plan, put it on, look at the fluoroscopy image and confirm that's where it is. Ideally, we get to the point where we just know where it's going to sit. We wouldn't have to look at the fluoroscopy until we're all done with it, right? That's where the evolution is going. Again, a little more invasive here, but the idea is that cut guide is made specifically for that patient. And yes, we can start making those smaller and smaller and smaller incisions for that as well. But we're at the forefront of this right now working forward. You can see here this rotation. Remember the rotation. So think about it, you can put this cut guide on and here for the bunion, for instance, and you see how right here, we want to make this cut and we want to make this cut, and that's going to help correct the bunion and -- but also the rotation filter, can you see that these 2 pin -- I can see down these pinholes, but I can't see down these. Here, I can see a little bit better. But what's going to happen is I want to make all these cuts and these pins will be in. And then I'll put another device on that actually just locks in and it takes those 2 pins and rotates them in alignment and drops in and then that corrects my rotation. So I don't even have to think about it. It's already all preplanned to make that a lot easier. And that's for the Adductoplasty as well. But you can see the pins are offset. When I put the next guide on, it drops them in, the rotation is already done. Based on my preoperative plan before I ever did step into the operating room, as I said. So here's the correction. You can see that the same implants, those are important. But what's really important, I have a way of reproducibly doing this operation and plan it all before the surgery. And what if you have this situation where somebody has just physiologically has a short first metatarsal. Well, as you can imagine, there could be some problems that the foot isn't balanced properly. Well, I can actually address that. I can -- in my plan and say, okay, I got to lengthen this bone this much. And I can plan that exactly how I need it to be. That right there all the way on the right is some bone graft. So there are donors out there, I can donate corneas and hearts. You can donate bone too. And these are precut. Treace has these too, so the surgeon doesn't have to sit there with a saw and try to get it just right and a lot of tailoring has to go into it. It's already premade for this particular problem in different sizes. Yes, it's human bone and then that is immediately available and can drop in so I can make up for that deficit in length and address that with the same type of fixation, but all preplanned. And that's the difference. So again, I think what's amazing about this, and I really think this is where it's going to go is that all this can be preplanned. Think about how predictable it is. When you go to your meeting, you feel very comfortable going in because you have your strategy, your plan of attack, and you know what the result is going to be because you're prepared. And that's the big difference. So all of this can be done, but with a preplanning in place, patient-specific instrumentation. Thanks.

All right. Thank you, Dr. Easley. Okay, that's loud. I'm Sean Scanlan. I'm Chief Innovation Officer at Treace Medical. I've been at Treace since just about the beginning. And I'd like to say I have the best job in the world. I get to work with big company, joined John Treace very early on that has invested in innovation since day 1, and we're still accelerating our innovation. We work with surgeons that are super talented, visionary and pioneers in MIS, Lapiplasty in this field. And then we have a mission at this company that is very clear, and we went through it a lot today. It's how do we bring triplanar correction, how do we democratize it for all surgeons in order to improve bunion surgery. We've done this through highly instrumented techniques that we can take a surgeon, do one training lab and they can get out and get a great result in any of these procedures. And we've worked hard over the last couple of years of how do we expand this 3-dimensional correction to the osteotomies to MTP fusion. And this is really a coming out party for us this year as we launch this full system. We also have these enabling technology platforms that we talked about through the different talks. And these are things we're going to continue to build on as we grow the company. So where are we going to play? How are we going to continue to grow? We talked about the bunion opportunity. It is still a massive opportunity that's underpenetrated. So through our open procedures, Lapiplasty, Adductoplasty, and then as we go into MIS procedures, we think we can move further up the funnel, as we talked about, bring more patients in that are on the fence for bunion surgery and expand through penetrating the bunion market. We're also going to use some of these core kind of technology platforms to expand the market and grow within the market, too. There's a lot of adjacent procedures with bunion surgery. There's 28 bones in the foot. There's other common pathologies associated with bunions. So how do we become one-stop shop with the best instrument and systems for all the different pathologies that surgeon needs to address in the bunion case. And so 5 growth drivers, and this is a bit of a summary of what I just went through. But number one, continue to advance our core procedures and penetrate the bunion market. Two, we're going to expand our portfolio into these other highly adjacent procedures with bunions, and we're going to do this by growing our 3 main platforms, our MIS systems, our SpeedPlate platform, and then also scaling the PSI digital solutions that we're working on as well. So this first thing is something that you've seen a lot today and something that we're super passionate about. So by being highly focused on bunions, we can continuously be very close to our surgeons and in these cases and become experts in these procedures and look at the unmet needs in the procedures to continue to make them better. So we're -- I like to call it kind of John mentioned kind of the iPhone model. We're always working on the next iPhone on the core Lapiplasty, Adductoplasty, and now the MIS and MTP systems. How do we make them easier to use, more reproducible, and then provide less invasive options for them as well. You can see an evolution. There's actually like 12 different versions of Lapiplasty over the past 10 years. And this year, we're actually launching at the end of the year, a limited release of our Lightning system, which is a way that really integrates Lapiplasty with SpeedPlate and makes it a truly hands-free system that's really conducive to the speed and efficiency of SpeedPlate. Also, as we've kind of been deep in these procedures and kind of attention to detail around what are the other unmet needs in the procedure? How do you make these procedures more efficient, faster and improve outcomes? And we've talked about a good bit of these single-use instruments. These are all highly unique to Treace. These are procedures specific. There are problems we see in the case and how do we make the case go better. Examples are, we talked about a little bit, LapiTome, you make a small incision, you make a bone cut. How do you get that bone slice out of the small incision without breaking the bone and having to dive in and pick it out. This is an Osteotome like a little chisel, but has a hook on the bottom, so you release the bone and then you can hook the bone and pull it out. The speed release it's common to do a -- it's called a sesamoid release at the big toe joint when you're doing Lapiplasty. We saw surgeons just using a scalpel and many of them would spend about 5 minutes digging around in their blindly trying to do the release. We found a very incomplete release affecting the outcomes. So how do we make a guided instrument that allows them to do that release very efficiently. So it both improves the speed and efficiency of the case, but also leads to better outcomes. And these have become a large part of our kind of revenue base in these procedures, too. And once surgeons try these, they can't go back to doing the cases without these tools. There's such great problem-solving tools. All right. So the second part of this is expanding our portfolio. And like I mentioned, there's 28 bones in the foot. There's a lot of other common pathologies associated with bunions. And so how do we take our recipe of highly instrumented techniques and address these other adjacent procedures, too. And we're just getting started into some of these different areas. And a couple of examples here, you saw in some of the cases in Akin osteotomy, which is an osteotomy to help straighten out the big toe joint. It's commonly done in bunion surgery. So often use a staple for this. Many of the staples in the market were very blocky, very prominent for the patient. So we're able to use our SpeedPlate technology platform and make a very low profile staple. You can see how well this staple fits to the contour of the bone. And then we also mentioned bone grafts. And so other procedures in the foot, flat foot, other things that we're moving into. How do you address those? And so we're able to use our SpeedPlate platform. You see in the bottom right bone graph to both lengthen the first metatarsal. But if you look in the back of the foot, that's actually in the heel, that's an osteotomy to address flat foot. So these are areas we're going to continue to build instrument systems, train surgeons on and bring these solutions to help really be one-stop shop for everything that's performed in a bunion case in addition to our core procedures. All right. So the third thing, and we spend a lot of time today, really excited about MIS and where this is going. And so how do we accelerate access to MIS? These are challenging procedures like we went through. How do we take our surgeon base, the majority of them are not doing MIS and how do we help train them and give them the tools to be very proficient in MIS after just one surgery. And you see a stat here. This is the fastest-growing area of bunion surgery when we pull our surgeons. MIS is also used in many adjacent procedures throughout the foot. So again, it a platform as we move from bunions also throughout the foot to other pathologies. And there's two really main limiters here in addition to the training. One is we talked about burrs. So a low-speed high-torque bur is used for MIS surgery. This is a capital piece equipment. How do we provide access to surgeons and they are able to do this. So we are announcing today a partnership where we can have a really plug-and-play MIS system that's dialed in for a foot and ankle surgery where they just plug in the handpiece and all the settings are pre-ready to go. And this is highly scalable for us in a very capital-efficient way to address MIS power systems And then the other side of MIS is how do we make instrumented systems like we talked about with Nano and Percuplasty that the surgeon can go to one lab and get a great result in their first case. So we're going to continue to iterate and expand on MIS and grow this throughout the foot. And then the fourth thing is expanding on our SpeedPlate platform. And so we've also covered this a bit through many of the talks, but this is a highly differentiated implant platform that only Treace Medical has. And the benefits are surgeons love nitinol staples have been in the market. They love the dynamic compression of nitinol staples. They're fast and easy to put in. They like the compression. But if you look at the data in the bottom right, this is some head-to-head testing that we did of our titanium SpeedPlate versus nitinol staples. Titanium is much stiffer. So you get a lot more compression from titanium kind of pound for pound. And then it's much better in fatigue. So as the patient walks, you can see the cycles of failure of the SpeedPlate in the bottom right, the red bars versus nitinol is much better in fatigue, so patients can [indiscernible] faster with these nitinol -- sorry, with our Titanium SpeedPlate technology. And then the other benefit, and we talked about how do we get into small incisions, is that we can actually do highly anatomic shapes and machining of titanium that you can't do with nitinol. So things like the MicroQuad would not be possible with nitinol, we can do it with titanium, make a very robust fixation through very small incisions. And we're also expanding with SpeedMTP into this hybrid fixation, which combines the best of both worlds. So you have the dynamic compression of SpeedPlate, but then you also get the locking screws of a typical plate. So that gives off-angle support and stability so that makes the SpeedPlate even more stable. So as we look at these other pathologies in the foot and as we continue to advance our core procedures, but also these adjacent procedures, SpeedPlate is a platform that we're going to be applying throughout the foot where we can make very anatomic designs in order to address many different pathologies throughout the foot. All right. And then the fifth one is PSI and other digital solutions. So Dr. Easley did a great job of who want a personalized solution to go in as a surgeon and to be able to communicate to the patient, here's your anatomy in 3 dimensions. Here's what I plan to do and know what the outcome is going to be, preplanned before you step foot in the OR. And so the challenges that we're planning to address here, and we've been investing in this area a lot is how do we bring software solutions and AI into this in order to make this highly scalable for Treace and for our surgeons and also just make it accessible for all surgeons out there. So how do we make the process easier, smoother and less costly so that we can expand this throughout the entire bunion surgery, which is a much more common procedure than something like total ankle we talked about. So super excited about where this digital technology is taking us from both a surgeon and intraoperative guidance, but also as a patient communication tool to help educate patients of what their pathology is and why they need bunion surgery and what the reconstructive plan is. So those are the 5 growth drivers that continue to grow Treace Medical as we expand from where we are now to kind of doubling the size of the company in the next several years. And that is all. Thank you, and we're going to take a little minute break and then do a panel Q&A. [Break]

Okay. Welcome back, everybody. We're going to start with Q&A. I'm going to start with a question for the panel up here. So we presented kind of the broad portfolio of bunion solutions. Curious how you see the average surgeon applying these in their practice and what their indications will be.

So one of the things that we talked about is mild, moderate, severe, and that's a kind of theme that will persist. As patients adopt new technology, they're going to do it most commonly in their comfort zone. And so like if it's Nanoplasty or Percuplasty, they'll start with that mild, moderate and then maybe over time, they can push that envelope. And that same thing happens with Lapiplasty. It happens with Adductoplasty. The SpeedMTP is something that could instantly be adopted in the patient's practices because this is what everybody is doing now. And we just have a solution that gives a better fixation option and with the compression and all the things that we talked about. So I think it will follow the patient's comfort zone. Just like Sean had said in his letter though, that's super important, you can come to literally one lab and then apply these technologies the next surgical day and have outcomes better than you probably ever had with a freehand technology.

Yes. I mean I think the only thing I'd add to that is that suddenly surgeons who are really just doing one procedure are going to branch out. So again, allowing the average surgeon and talking more about the percutaneous surgery to open up their options to patients. So when they see a patient that comes in and says I want minimally invasive surgery instead of the surgeon saying, "Oh, you're going to have to go see my junior partner because I don't do that surgery, he or she can actually do that surgery." So I think it just really opens up the toolbox for the surgeon to have more options for everything that the patient wants and needs.

Yes. I mean, I would echo the same thing. I think every surgeon probably has two or three procedures that they want to have in their toolbox. And I think that there's probably one that's predominant and then they'll have their outliers. Every surgeon is probably going to want an osteotomy procedure. Every surgeon is going to want a Lapiplasty procedure and then every surgeon is going to want an MTP fusion because patients have arthritis without bunions. But then the beauty of it is every surgeon is going to have continued literature showing it's important. So I think each surgeon wants two or three options for their bunion procedures, and that kind of fits that need.

I'm going to go back to -- I mean, these are great answers. I'm going to go back to the principles. So the surgeon education component that Treace does well. And again, I didn't start with Treace. I was very impressed with what the philosophy is. And I think that's what's really important. We had a conference -- Jonathan and I did, we have a weekly conference with our team. And one of our colleagues is an excellent surgeon, does a really good job. He had a bunion surgery, and we talked about things that didn't go quite the way we wanted to, and he shared a case with us. And to Jonathan and me, it was quite obvious what was missing. But to him, he did a surgery well. He put the implants in properly and everything was done technically appropriately, but he didn't quite have the full principles. And once we shared some of those concepts with them that we -- that are very familiar to us, he said, "Oh, I see what you're saying now." And I think that, that's what Treace can do is that, yes, we have all these great implants. And yes, they are these great techniques, but it's really understanding the surgical principles behind it. That's what you do well. So that's the instant impact, I think, that can be made. And so with Treace out there, it can be peer-to-peer. They offer peer-to-peer surgeon interaction or these bigger bunion master courses, which you maybe have heard of. But anything from one-on-one to bigger scale teaching opportunities and webinars, that's the key that will help drive all the success for the surgeon and for the patients.

Great. And I appreciate those answers. And then relative to the learning curve in MIS and Dr. Kaplan with Nanoplasty, what are you seeing the learning curve be for Lapiplasty with the surgeons that you're helping train?

Yes. So the learning curve, Holly touched on a little bit. And I vividly remember, I think I was 10 surgeries into my MIS bunion adventure, and I was struggling and I was frustrated. I remember exactly where I was standing in our surgery center when I said, why am I doing this to myself? Because there's a notable learning curve, and it's probably Holly hit the nail on the head when she said it's about 40 or 50 with the traditional MIS bunion procedures. And I think that's probably the coolest feature of the Percuplasty and the Nanoplasty. I know this sounds extreme. I think the learning curve is probably maybe 2 to 3. And the reason I say that is we're training surgeons. We'll have surgeons that will come to one of our training labs. They'll do it the first time. It will be smooth, seamless. And then they'll reach out to us before a case because we do peer-to-peer direct interaction. They'll do the case and we get follow-up. And usually, I've seen as little as 2 or 3 surgeries where the surgeon is saying, it went the way I wanted it to go. We look at their x-rays, their x-rays look good. There's good alignment. And the representation, the people that are watching them do it also say to us, that went the way the lab went when you train them. And so I think it's drastically decreased that learning curve, and I think that's going to be the biggest adaptation of those procedures.

And I just want to clarify one thing. The first 2 of the 3 say, it's not that the case went poorly and the patient had a bad outcome, and that's really important. It's just that maybe it took a little bit longer. Instead of taking 35 minutes, it took 55 minutes. So it's not the way that the instrumentation is designed, so you can't screw it up. And so even though there's maybe 1 or 2 cases where it takes a little longer and you're getting used to it, you're not going to have a bad outcome, whereas with the more old school freehand technique with MIS, I mean, I've seen some disasters that people have had with their initial cases because they didn't know how to do it well. So we've eliminated that part of the learning curve.

Yes. And I mean, touching on the learning curve before these systems, if you logically think if it takes 50 procedures to be even just comfortable and proficient with, not even an expert, if a surgeon does 25 to 50 in a year, it's going to take them a year of struggling and nobody wants to struggle for a year. I mean imagine when you're learning how to drive a car, if you had a car accident every month for the first year, you probably wouldn't drive, right? And that's what happens with these bunion procedures is when you struggle through it and you have these car accidents, you almost don't want to do it anymore.

Yes. What's also interesting about these systems are it's almost like a third hand or a second person in the OR. They're all at major teaching facilities. So they have students, residents, fellows. But the vast majority of foot and ankle surgeons across the country are maybe alone in some community offering these technologies. And what this does, this offers another skilled hand, so to speak, through the instrumentation, which is invaluable because Holly accurately said, you need somebody to hold the deformity, you need somebody to throw it. Well, that, by definition, is two skilled hands. And if you guys aren't surgeons, we're surgeons. But if you have a tech in the room that maybe isn't very keen to how to hold, then you need two skilled people. So this really eliminates a lot of issues with reconstructive surgery around bunion deformity.

Ryan Zimmerman from BTIG. Thanks for putting on the day and attending here. Two questions for me. One, there's an abundance of new products. They all seem like really good incremental offerings for the company. Can you just talk about your facility's willingness to spend incremental dollars for these products relative to other products that may be more inexpensive and out there in the market? And then the second question is, in your mind, as physicians, how does Treace launch all these products successfully without maybe overwhelming the physician population around the country because there is a lot out there.

So two great questions. One of the things -- I'll start with the second one. One of the things when you had said about overwhelming, and you heard a consistent theme, each surgeon has in their mind an approach in order to do this. What Treace does is offers the platform. So if they want to do osteotomy MIS or they want to do a triplane tarsal, metatarsal like Lapiplasty or whatnot, you have the ability in order to do that. So it's really surgeon preference. And then to go to number one, a lot of times, what's happening at the facility because the facility may just be looking at comparison [indiscernible] they don't really understand. Once the surgeon gets their hands on this technology with Treace products, the surgeon goes to the facility and fights for it harder than anybody else would because they instantly see the value of it. So what I can say in my practice, what I did is said, "Hey, these are my patients and here's what I'm going to use, and this is the technology I need." And the value add speaks for itself. And so then the companies go forward with that.

I can speak from having worked at two academic centers, the Hospital for Special Surgery and MGH in Boston. And so when you want to bring new product in, especially at two facilities like that, that have a lot of power over what comes in, offering a huge patient population and surgeon populations. HSS specifically, they can negotiate pretty much any price they want. And so Treace comes in at the same level as the competitors. And I think that, that's going to be really important. But if they're offering -- if Teresa's product -- and this is where the surgeon argument comes in. If I say -- if I go to the gatekeeper of instrumentation and I say, look, I can do this procedure 30 minutes faster if I have this jig, and I -- that means I can do two more cases in a day, they're going to bring that product on immediately. And so it really hasn't been an issue bringing them in. And of course, there has to be some negotiation of prices, but it's not like these price points are crazy different than what's out there. And then to address your other question, every foot and ankle surgeon is doing all of these procedures. So it's not like there's this -- oh, we're introducing these new concepts. It's -- of course, there's a concept around 3D triplanar correction, but it's about doing the procedures that you're doing all the time and making it easier and faster. So it's -- you're not going to get overwhelmed with the product because the concept is still the same. It's just, okay, you have this really easy technique that I'm now going to use to take care of this difficult problem. And so most surgeons would adopt the whole portfolio very easily.

Yes. And I think speaking on that, too, I mean, Holly and I didn't really get into the osteotomy world. There's over 50 different ways you can do osteotomies. And so I think the way you avoid overwhelming surgeons is coming out with a technique for every single osteotomy, whether it's Chevron, an Akin, a MAO, a Ludloff. I mean I can just rattle off a lot of names. So I think it's having that armament where you give each surgeon the option of what they want, at least within the theme of an osteotomy, a first TMT arthrodesis, but then streamlining the rest of it. And then on the first question, I mean, my background is I'm at Duke University now, but I was in private practice for 10 years in California before that. California notoriously is hard from a cost standpoint everywhere. And I think from being a private practice, though, what we recognize, too, is there's value that goes beyond the individual dollars as well. So your patient outcomes affect your outcome. Our surgery center was connected to our clinic, which was connected to our orthopedic hospital. And a patient saw all of that as one entity. So if they had a good experience within any of those, that translated to positive outcomes. And like Holly said, too, the more efficient you are in the operating room, a, that decreases the cost because the dollar -- the expense of healthcare is how long you're in the operating room. And then the second thing is the more cases you can do improves reimbursement. So I can't speak on the specifics of how our facility negotiates the prices, but there is collateral benefit that we see with these types of systems, and they recognize that.

I think you're right. Treace -- I mean, some of this is pretty involved. It's intricate technology. So it warrants -- and there's more production cost behind that. I think Treace is very efficient, and I'll let the Treace team speak to that. But what's really important is what's the #1 worry we have with bunion surgery. Is that the damn thing recurs, right? We're trying to avoid it recurring. So this is a very reproducible way, whether it's MIS or it's done with the more maximally invasive surgery that I showed, showing that it's a reproducible procedure that gets reproducible outcomes and the recurrence rate is really low. And what Treace does a good job of, if you look at the literature, there's a lot published on how good the results are in the MIS. I mean, you do in your research, too, so that will soon follow to show. And I think that hospital systems will recognize that. Yes, the patients will be happy. That's important. But also you can say the recurrence rate is low, meaning that the patient most likely won't have to have a reoperation. It's not foolproof, but it's certainly a lot better than what's out there. right? And as far as the other question where you said, how are you going to overwhelm the surgeons or overwhelm the market with this? Not really. Like it was said that all these procedures are done. What's frustrating sometimes is Treace did a very good job of entering the market with a very specific product, very specific technique, and it was very -- so effective that everybody else actually mimicked it, right? And so definitely a leader in this field, but very narrow. But there are times you say, gosh, there's arthritis, I'd like to be able to do a fusion of the big toe joint or the bone is a little bit short. What if I had a way to lengthen a little bit. So you don't want to have to call on another vendor, have somebody else there. So now it's a complete portfolio where every situation that's encountered can be addressed. And then you also have different instruments to make those techniques easier, and I think surgeons gravitate toward that. The other thing I'd say, Will did a very nice job of showing you that patients understand that, too. You saw that little schematic little drawing of moving the metatarsal, moving the bunion, and I think you can conceptualize that. It's really amazing when you take that not just as a 2-dimensional drawing and put it in 3 dimensions and have that patient-specific instrumentation. So yes, maybe not everybody right now can get that CT scan and put that through the process of doing a 3-dimensional surgery. But look over the next 3 to 5 years, and it's going to go there. It's going to be much more accessible and Treace is already there and make that easier as part of the portfolio.

Rich Newitter from Truist Securities. Thanks for doing this day. It's really helpful. I have a couple. The first is just on how SpeedPlate MTP fits in with the rest of these solutions. Are you -- was it a situation where people were coming in, maybe asking for Lapiplasty and they ended up having a big toe arthritis and they were -- you didn't treat the bunion, you treated the arthritis? Or is this a situation where you're doing -- you're always treating the Lapiplasty and on top of that, you're doing the toe arthritis too. So you're getting two procedures really for that one patient. I'm just trying to get a feel for how it's plate MTP, whether it's more procedures per patient or if it's something that just allows Treace now to participate in the big toe arthritis where they had to hand it off to someone else, but they got the patient in from Lapiplasty. I'll just ask my -- well, let's go there and I'll ask the second one after that.

So it's a great question. Every bump around a big toe to a patient is a bunion. So first off, they come in, they have a bump, they have a bunion, and they may just have arthritis. There are two subsets of arthritis around the big toe. There's primary arthritis, so no angular deformity of the -- what we call the metatarsal, so no bunion, and that can be caused by trauma or these sorts of things. And then there is also a bunion with arthritis. And that's a lot of times people with long-standing abnormal alignment, then the joint kind of breaks down. And to answer your question, there's two trains of thought for that. We were doing first MTP fusion with our plating system. We were doing the same BIPLANAR plating. But by and large, what surgeons use is a dorsal locking plate with an interfrag screw. And so we wanted an offering that did that because that's the kind of the traditional way to do it. What SpeedPlate did is did a slimmer plate. It's actually the thinnest plate on the market. So we can still see the fusion. It doesn't create a prominence around the skin. That soft tissue is not very robust in that area and the continuous compression really changes it. And then to put a bow on the end of your question, sometimes patients come in and they have a deformity where that metatarsal is egregiously out of alignment. And maybe the first MTP fusion, the SpeedPlate alone can't get full reduction, and we do a procedure that we internally and we published on it called a double procedure. So in those cases, they are getting Lapiplasty with the first MTP fusion. And we have radiographic and functional outcome that we published that are just phenomenal. So this is one more step.

What percentage of the time is that?

I would say maybe 10% of the time.

Yesterday, it was 100%. But I like to have the solution, right? And it's -- yes, certainly, I could use any system to try to fuse both. But let's take, for instance, yesterday, I was -- I had two surgeries where I was going to do a fusion of the big toe. I like the Treace system, so I have that ready to go. And I did it, but it didn't fully correct it or that other joint was so unstable that I couldn't get the alignment I wanted. I could immediately add this the Lapiplasty principles and get it right with the double. So I think that's important. The other thing I want to answer is it's not really trying to get too far out of something. It's really trying to do the right thing for the patient. And so I have a solution where I think some surgeons say, I've done the first big toe fusion. Yes, something doesn't seem quite right, that's good enough. And maybe that's okay. But I like the dedication this team has to doing the right thing and making sure it's perfect. And that -- if you fuse that other joint in the proper position and fuse the big toe joint, the patient will function exactly like if they only have a first big toe joint fusion. The other thing that you need to know is that Treace is very careful in what they do, and this is just what I've observed. So it's very focused and been focused for years on Lapiplasty, right, and trying to get the big toe and get the rotation right and correct the bunion, not really thinking about the big toe joint. Yes, if there's arthritis, we need to fuse it, but not really focusing on having a specific system out there for that. Will and I and others, we really kind of pushed Treace towards that, there's an unmet need here. We can make this better. And so Treace listened. And so I think I'm very impressed with the resources put toward that to make that operation that I mentioned was relatively common. But in my opinion, I think others would agree that it's better now.

Can I just ask one follow-up? It would be great just to hear from the doctors. Just on volumes, I know we're entering what the company is called bunion season. And I'm just curious if you could compare and contrast the demand curve that you're kind of seeing in September and what you know you have booked out into October or even further than that compared to maybe this time last year? Is it about the same, less, more?

I can say from my own practice and New York City is a little bit different because the summer tends to be slow. Nobody in the Northeast wants elective bunion surgery when we finally have a couple of months of great weather. So it slows down a little bit, I think, for everybody, HSS sees it across the board. I will say that from a bunion standpoint, I'm completely maxed out. I'm literally -- I'm maxed out basically until Christmas, and I had to add 2 more OR days in September because we have AOFAS coming up. I'm constantly looking for more OR time. And so for me, personally, my volume could continue to keep going up, and I have no limit. The limit is literally that I can't get more block time in my hospital. So -- and as I think I alluded to when I was up there, my practice when I started doing minimally invasive surgery in 2017, when I came to HSS in 2018, it probably took about 1.5 years and then my entire practice just became much, much smaller. As I start doing -- and I don't do any marketing, people now want -- I feel like I fixed every bunion in the Manhattan and still the people keep coming. So I guess my short answer would be, literally, the sky is the limit. And I would see myself doing 20% more volume this probably, if we look at year-on-year, probably in 2026 than I have in 2025.

Yes. I mean I think to echo that, and I think Holly and I are in a unique spot because the minimally invasive procedures are self-referring. I mean, like Holly alluded to, they just grow because someone has it and then their friend or family wants it. I can't speak on the national levels, but my year-over-year growth just continues to grow because of those minimally invasive procedures because patients are becoming more and more informed about it, both by way of knowing someone who had it, but also online resources and learning. And so I think it just continues to grow. The end of the year historically is usually a busy time of the year, not just because of seasonal changes, but also because of year-end deductibles and co-pays and things like that. And so I think just logically, it's continued to grow volumetrically each year just by way of what we do and how we do it and then outcomes being good because if a family member does well, there are other family members going to come. I have a family that has 7 sisters, and I've done 6 of their bunions. And the seventh is coming at some point, she's just waiting until it's convenient for her. So it just -- it's a self-growing system that I think works well in general.

Arthur Weise from Kingsland Investments. Just a question for each of you. Very simply, what percent of the procedures that you do, you use a Treace procedure. How long did it take you? How many years to get to that point? And for those that you don't, why is the main reason?

So I could start, we'll go down the line. So for my practice, personally, I use 100% of Treace offerings for all these pathologies. So I've been a part of Treace from a consultant and then a design surgeon for about 10 years. So since 2015, I started with them. It's interesting because the common theme that you hear from surgeons, and I had my own realization as well is this bunion, I did better than I've ever done it before. And then that creates this kind of groundswell and this momentum, not even just for you, but for patients. And that's what Jonathan and Holly and everyone is talking about that word of mouth continues to persist. So what Treace does is have the offering for all the midfoot, forefoot deformity. So in my practice, it's 100%.

For me, if we're thinking just forefoot, I use only Treace as well. I don't do open -- I do pretty much everything minimally invasively. So for instance, the first MTP fusion, I'm not using SpeedPlate, but I'm using Treace screws and the Treace burrs and the Treace system to get my fixation. In the midfoot, I do my metatarsal adductus correction and I use the SpeedPlate for that. So I'm using it for all of my forefoot. And then in addition to that, when I have any need for a 4-0 screw or a 3-0 screw if I'm doing something in the midfoot or even an ankle fracture or something like that, I'm also throwing Treace screws as well. So basically, anywhere where I can use that system, I'm using it. I think that all of us -- we don't only do forefoot surgery. So for the non-forefoot surgery, probably the other -- 1/3 of my practice is sports. As soon as John is willing to jump into the sports market, I'm in. So we just don't have that yet.

Yes. My answer is very similar to Holly's in that I do a lot of minimally invasive surgery beyond the forefoot as well. And I'm pretty much for all these pathologies that there is an option I'm using a Treace product to go beyond the things I feel like I'll just beat a dead horse with what Holly does. We use screws all over the foot. We use these Percuplasty screws throughout the foot and the ankle. I use the FastGrafter. I do a lot of bone graft for my fusion. So I use the FastGrafter a lot as well. And now with the CortiFuse, the biologic, we can use that as well, both minimally invasive open. And so for me, if there's a Treace product that I can use on the patient, I am, similar with sports, it's a soft tissue line. And then I think to answer your question of how long it took, I mean, some of these products are newer. So the percuplasty screws have come out this past year. And so that's where the evolution has changed where it's just continued to increase volume each year as these products have come out.